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Research and Projects

Avoidable Acute Admissions (AAA)

Who is involved?

Theme: CLAHRC - Person-Centred Care
Status: Complete

Read a BITE-sized summary of this project.


Emergency admissions to hospitals have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical admission units (MAUs). These pressures can adversely impact patient experience through overcrowding and potentially suboptimal clinical decision-making. Solutions proposed to meet demands for emergency care include: development of new units linked to emergency departments, earlier senior input, and hospital-based teams to support discharge. However, the cumulative effect of these alternative care models, on patient and clinician experience, has not been fully investigated.

The NIHR HS&DR funded the Avoidable Acute Admissions project (2012-14) to investigate how clinician expertise and decision-making in four hospitals in South-West England contributed to safely reducing acute admissions.

The project used a mixed-methods case study design for a comparative analysis of decision-making about admissions in four acute hospitals in south-west England. The primary research comprised two parts: value stream mapping (VSM) to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers, and 282 practitioners of different specialties and levels.

Additional data was collected through a Clinical Panel, Learning Sets, stakeholder workshops, Reading Groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources. Find out more on the project webpage

Project aims

The study aimed to investigate the interplay of factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.


The project found that medical and social complexity, targets and ‘bed pressure’, patient safety and risk, all influenced decision-making about admission and discharge. Each hospital site responded to these pressures with different initiatives designed to facilitate timely, appropriate and safe decision-making. New ways of using hospital ‘space’ were identified, for instance, clinical decision units and observation wards allow patients who are potentially dischargeable but have complex social or medical needs to be ‘off the clock’, allowing time for tests, observation or safe discharge.

Health care staff contribute to avoiding unnecessary admissions: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment; and senior doctors provided advice and training to other staff members. 

Read the project report to find out more about the project's conclusions. 


Pinkney J, Rance S, Benger J, Brant H, Joel-Edgar S, Swancutt D, et al. How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals. Health Serv Deliv Res 2016;4(3). DOI: 10.3310/hsdr04030


A news article about reducing avoidable acute admissions to hospitals is available to read on our news pages.

In this article, Professor Jonathan Pinkney discusses the link between avoidable acute admissions and pressures on the NHS.

Conference proceedings

  • D Thomas, D Swancutt, S Joel-Edgar, H Brant, R Byng, J Pinkney.  Emergency or ambulatory? GP hospital referral routes for acute patients. Society for Academic Primary Care. Feb 2015, Birmingham
  • S Rance, J Pinkney, H Brant, D Westlake, D Swancutt, I Holme, S Sharkey, R Byng.  Time for care? Patients’ and emergency practitioners’ voices.  Emergency Admissions Conference, Dec 2014, London
  • S Rance, H Brant, D Westlake, D Swancutt, I Holme, S Sharkey, M Pearson, J Pinkney & R Byng.  Embedding ethnography within critical realism: methodological challenges in a study of hospital emergency care. The 1st International Conference on Realist Approaches to Evaluation and Synthesis (CARES) Oct 2014, Liverpool
  • S Rance, J Benger, H Brant, D Swancutt,  D Westlake, D Thomas, I Holme, S Sharkey, A Gibson, J Pinkney, R Byng.  Emergency department practitioners’ voices on workplace pressures.  Dilemmas for Human Services. 17th annual international research conference. Sept 2014, London.